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Mar 31, 2016

A jab in time Some Western countries have lower vaccination rates than poor parts of Africa. Anti-vaxxers are not the main culprits

International Vaccination

The Economist
March 26, 2016

ERADICATING a disease is the sort of aim that rich countries come up with, and poor ones struggle to reach. But for some diseases, the pattern is reversed. These are the ailments for which vaccinations exist. Many poor countries run highly effective vaccination programmes. But as memories of the toll from infectious diseases fades across the rich world, in some places they are making a comeback.

The World Health Organisation (WHO) reckons that vaccines save 2.5m lives a year. Smallpox was eradicated in 1980 with the help of a vaccine; polio should soon follow. In both cases, rich countries led the way. The new pattern looks very different.

The trend is most evident for measles, which is highly contagious. At least 95% of people must be vaccinated to stop its spread (a threshold known as “herd immunity”). Although usually mild, it can lead to pneumonia and cause brain damage or blindness. The countries with the lowest vaccination rates are all very poor, but many developing countries run excellent programmes (see chart). Eritrea, Rwanda and Sri Lanka manage to vaccinate nearly everyone. By contrast several rich countries, including America, Britain, France and Italy, are below herd immunity.

Last year Europe missed the deadline it had set itself in 2010 to eradicate measles, and had almost 4,000 cases. America was declared measles-free in 2000; in 2014 it had hundreds of cases across 27 states and last year saw its first death from the disease in more than a decade. The trends for other vaccine-preventable diseases, such as rubella, which can cause congenital disabilities if a pregnant woman catches it, are alarming, too.

This sorry state of affairs is often blamed on hardline “anti-vaxxers”, parents who refuse all vaccines for their children. They are a motley lot. The Amish in America spurn modern medicine, along with almost everything else invented since the 17th century. Some vegans object to the use of animal-derived products in vaccines’ manufacture. The Protestant Dutch Reformed Church thinks vaccines thwart divine will. Anthroposophy, founded in the 19th century by Rudolf Steiner, an Austrian mystic-cum-philosopher, preaches that diseases strengthen children’s physical and mental development.

In most countries such refuseniks are only 2-3% of parents. But because they tend to live in clusters, they can be the source of outbreaks. A bigger problem, though, is the growing number of parents who delay vaccination, or pick and choose jabs. Studies from America, Australia and Europe suggest that about a quarter of parents fall into this group, generally because they think that the standard vaccination schedule, which protects against around a dozen diseases, “overloads” children’s immune systems, or that particular vaccines are unsafe. Some believe vaccines interfere with “natural immunity”. Many were shaken by a claim, later debunked, that there was a link between autism and the MMR vaccine, which protects against measles, mumps and rubella.

In America, some poor children miss out on vaccines despite a federal programme to provide the jabs free, since they have no regular relationship with a family doctor. Some outbreaks in eastern Europe have started in communities of Roma (gypsies). Members of this poor and ostracised minority are shunned by health workers and often go unvaccinated.

Several governments are trying to raise vaccination rates by making life harder for parents who do not vaccinate their children. A measles outbreak last year that started with an unvaccinated child visiting Disneyland and spread from there to seven states prompted California to make a full vaccination record a condition of entry to state schools. The previous year, in a quarter of schools too few children had been vaccinated against measles to confer herd immunity. A dozen other states are considering similar bills. After a toddler died from measles last year, Germany recently started to oblige parents who do not wish their children to be vaccinated to discuss the decision with a doctor before they can enroll a child in nursery. Australia’s new “no jabs, no pay” law withdraws child benefits from parents who do not vaccinate, unless they have sound medical reasons.

Persuasion, a fine art

There is, however, surprisingly little evidence that tough laws make a big difference to vaccination rates. European countries that are similar in most respects (such as the Nordics) may have similar rates for jabs that are mandatory in one country but not in another—or very different rates despite having the same rules. Rates in some American states where parents can easily opt out are as high as in West Virginia and Mississippi, which have long allowed only medical exemptions.

And strict rules may even harden anti-vaccination attitudes. Australia had previously made exemption conditional on speaking to a doctor or nurse about the benefits of vaccines. The new rules mean fewer chances to change parents’ minds. Research suggests that making it harder to avoid the most important vaccines may make it more likely that people who strongly oppose vaccination in general shun optional ones, says Cornelia Betsch of the University of Erfurt.

More important, say public-health experts, is to boost confidence in the safety of vaccines and trust in the authorities that recommend them—both badly damaged in many European countries by pastpublic-health mis-steps, such as a scandal with contaminated blood supply in France from the late 1990s. The best way to handle a vaccine scare is to express empathy and promptly share the results from investigations of alleged adverse reactions, says Heidi Larson of the London School of Hygiene and Tropical Medicine. British authorities’ dismissive response to the MMR scare failed to reassure worried parents.

One promising new approach is to keep track of the vaccine myths circulating in cyberspace and rebut each one as it appears. This requires tracking information from search engines and following anti-vaccination websites and parents’ forums. On one such forum, worriers say they have scoured government and vaccine-manufacturer websites but feel overwhelmed by information that they regard as inconclusive or contradictory. One mother seeks advice on how to get around California’s “fascist” new rule. Another casts doubt on a study on severe allergic reactions to vaccines: 33 cases from 25m jabs, she says, seems “fishily low”.

Some countries are starting information campaigns that treat such concerns with respect. A parents’ organisation in Bulgaria launched one recently, under the auspices of the ministry of health and the national association of paediatricians. Its website is jargon-free and easier to navigate than unwieldy official hubs. France is launching a national dialogue on vaccines this spring, with a website where citizens can swap gripes, worries and advice.

Although vaccine-hesitant parents often search for answers on the internet, their most trusted sources are doctors and nurses. The WHO recently developed guidelines to help health workers figure out, through a questionnaire, which type of worrier a parent is—and how to alleviate specific concerns. But recent research from several European countries shows that many doctors and nurses are also hesitant about vaccines, for much the same reasons as their patients. In a survey conducted in 2014, 16-43% of French family doctors said they never or only sometimes recommended some of the standard vaccines.

An additional problem is that many adults were not immunised as children and have not caught up since. In the 1970s and 1980s, when the measles vaccine was new, many children did not receive it, or got just one shot, which is now known not to be reliable in conferring immunity. Some countries offer free catch-up jabs to some adults when outbreaks flare up—usually parents with small children and health workers in affected areas.

But such efforts have, on the whole, been too little, too late. The return of easily preventable diseases that had all but disappeared is a shame. A bigger shame would be for governments to continue blaming it all on ignorant parents.

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